Climate change and public health in Germany - An introduction to the German status report on climate change and health 2023

Global warming of 1.5°C and even 2°C is likely to be exceeded during the 21^st century. Climate change poses a worldwide threat and has direct and indirect effects on infectious diseases, on non-communicable diseases and on mental health. Not all people are equally able to protect themselves against the impacts of climate change; particularly populations that are vulnerable due to individual factors (children, older persons, those immunocompromised or with pre-existing conditions), social factors (the socially disadvantaged), or living and working conditions (e. g. people who work outdoors) are subject to an increased risk. Concepts such as One Health or Planetary Health provide a framework to frame both climate change itself and adaptation strategies or sets of actions for environmental human and animal health. Knowledge of climate change impacts has grown in recent years, and mitigation and adaptation strategies have been developed.

[Four years after the Ebola crisis : Challenges, experiences, and implications in the German public health context]

The Ebola virus disease outbreak in West Africa in 2014/2015 was by far the biggest, most prolonged, and geographically most widespread outbreak of this disease since the discovery of the Ebola virus in 1976. Although no cases of Ebola virus disease were confirmed in Germany, a number of crisis management activities were initiated.Based on a combination of local, national, and international lessons learned, literature research, and a large number of discussions among German colleagues as well as German and foreign colleagues, the experiences of selected German public health actors as well as implications for health protection activities in Germany are presented.On the one hand, preparedness for managing unusual high consequence health events-caused by rare, highly pathogenic biological agents-including the provision of adequate material and personnel resources remains important in Germany. On the other hand, more German engagement in global health is necessary, because the dividing line between global health and local health is increasingly disappearing.

[Incident-crisis-disaster. Conceptualizing unusual biological incidents]

Unusual biological threats demand adequate preparedness efforts, as demonstrated, for example, by the Ebola virus disease outbreak in West Africa in 2014/2015 and pandemic influenza in 2009/2010. In Germany, responsibilities for such efforts are located in different governmental authorities and differ from state to state. As a result, there are many different preparedness approaches using divergent core terminology.In this article a common definition for the term "unusual biological incident" is proposed. To do so, a literature review as well as semi-structured expert interviews with representatives of central actors in Germany were conducted. The understanding of "unusual biological incident" was not consistent among experts; four approaches to qualify a biological incident as "unusual" were identified. These were merged in a comprehensive system-oriented approach that focuses on the health system's resilience and on shortages of knowledge and material resources during incidents.Based on this approach, we suggest a stage model for the categorization of biological threats as "incident," "crisis," "severe crisis," or "disaster." The need for central coordination is a defining characteristic to qualify a biological incident as "unusual." Based on the identified shortages, the necessary response strategies can be derived.

Germany's expanding role in global health

Germany has become a visible actor in global health in the past 10 years. In this Series paper, we describe how this development complements a broad change in perspective in German foreign policy. Catalysts for this shift have been strong governmental leadership, opportunities through G7 and G20 presidencies, and Germany's involvement in managing the Ebola virus disease outbreak. German global health engagement has four main characteristics that are congruent with the health agenda of the Sustainable Development Goals; it is rooted in human rights, multilateralism, the Bismarck model of social protection, and a link between development and investment on the basis of its own development trajectory after World War 2. The combination of momentum and specific characteristics makes Germany well equipped to become a leader in global health, yet the country needs to accept additional financial responsibility for global health, expand its domestic global health competencies, reduce fragmentation of global health policy making, and solve major incoherencies in its policies both nationally and internationally.

Some personal notes on role plays as an excellent teaching tool : commentary on "using and developing role plays in teaching aimed at preparing for social responsibility"

Role plays are extremely valuable tools to address different aspects of teaching social responsibility, because they allow students to "live through" complex ethical decision making dilemmas. While role plays are getting high marks from students because their entertainment value is high, their educational value depends on their closeness to students' work experience and the skills of the teacher in helping students comprehend the lessons they are meant to convey.

Case Study – Bulgaria

The aim of this paper is to map the current situation in Bulgaria’s public healthcare system with regard to bioterrorism response. It explores the main public health threats and focuses specifically on the changing perception of bioterrorism as a potential threat to the country. Furthermore, it explains how this perception is reflected in the existing legal framework and administrative structures. The paper makes the case for the further development of an integrated, flexible and sustainable national management system to respond effectively to emergencies and presents the major challenges for the country in this field. It makes a comparison between military and civilian agencies in their preparedness to respond to naturally occurring emergencies and threats of biological attack. This review points out the higher but still limited capacity of the military medical facilities in Bulgaria. The overall evaluation underlines the need for further strengthening of the relationship between military and civil capabilities and between public healthcare and security and law enforcement structures. As a result the authors make the case for stronger cooperation between military and civil medical facilities as well as for inter-institutional and interdisciplinary dialogue on the expert and political level on biopreparedness in Bulgaria.

Case Study – United States of America

The United States (US) considers the intentional use of a biological agent a serious national security threat. Over the last decade, federal, state, and local governments in the US have made concerted efforts to enhance preparedness within the public health, medical, and emergency response systems to address this threat. These activities span a wide range of areas from the enactment of new legal authorities and legislative changes to significant financial investments to enhance multiple detection and response system capabilities and the adoption of a national command and control structure for response. Many of these investments, although prompted by the concern for bioterrorism, have served to strengthen public health, medical, and emergency response systems overall and have proven invaluable in responses to other large-scale emergencies, such as the 2009 H1N1 influenza pandemic.

Case Study – Germany

Public health structures in Germany reflect the federal system: health care in general lies within the responsibility of the 16 constituent states and the federal government only acts if a state asks for assistance. There were no bioterror-related intentional releases of biological agents in Germany in recent years. The potentially devastating effects of such an incident require sound public health preparedness planning. The Basic Constitutional Law (Grundgesetz) does not allow the deployment of armed forces within Germany with some rare exceptions. However, there is a well-established civil-military cooperation. The Federal Armed Forces (Bundeswehr) are deployed in humanitarian and multinational UN or NATO crisis containment missions abroad, requiring adequate protection from pathogens and diseases endemic or enzootic to those regions. Both, the military and the civil public health system are complex structures that contain administrative, care giving, medical investigation, and research capabilities in order to cope with natural, accidental or intentional biological incidents.

Health Security and Disease Detection in the European Union

In a globalised world, national and international institutions in charge of health security can no longer only rely on traditional disease reporting mechanisms, not designed to recognise emergence of new hazards. New approaches are developing to improve the capacity of surveillance systems in detecting previously unknown threats. More recently, surveillance institutions have been actively searching for information about health threats using internet scanning tools, email distribution lists or networks that complement the early warning function of routine surveillance systems. Since its foundation, ECDC has developed an epidemic intelligence framework that encompasses all activities related to early identification of potential health hazards, their verification, assessment and investigation, in order to recommend public health control measures. Since June 2005, about 900 threats have been monitored by ECDC. Several threats made it necessary to develop formal risk assessments or to dispatch ECDC experts to outbreak areas. Examples of recent events, identified through the epidemic intelligence activity, are presented to illustrate the course of action from threat detection through risk management in Europe.

Case Study – Italy

After the peak of interest in 2001, the threat of bioterrorism is now considered just one of the diverse risks Italy’s society faces endangering public health. Without major investments, the effort has been to integrate existing resources, to implement tight links among national and supranational agencies and to make plans for their most efficient involvement in case of need. The mainstay for the response to a biological attack is represented by the public health system, entrusted to Italy’s national health service, centrally coordinated but put into action by the Regions. The emerging threat of emerging infectious diseases and of bioterrorism has shown the need for a change in the education curricula of sanitary professions and for specific training of first line operators. Specific courses have been activated by universities and other bodies, but attendance has been limited by the lack of ad hoc funds.

Unfinished business: efforts to define dual-use research of bioterrorism concern

Biotechnological research poses a special security problem because of the duality between beneficial use and misuse. In order to find a balance between regulating potentially dangerous research and assuring scientific advancement, a number of assessments have tried to define which types of research are especially open to misuse and should therefore be considered dual-use research of special concern requiring rigorous oversight. So far, there has been no common understanding of what such activities are. Here we present a review of 27 assessments focusing on biological dual-use issues published between 1997 and 2008. Dual-use research activities identified by these assessments as being of special concern were compiled and compared. Moreover, from these 27 assessments, the primary research publications explicitly identified as examples of concerning research activities were extracted and analyzed. We extracted a core list of 11 activities of special concern and show that this list does not match with the reasons why primary research publications were identified as being of special concern. Additionally, we note that the 11 activities identified are not easily conducted or replicated, and therefore the likelihood of their being used in a high-tech mass casualty bioterrorism event should be reevaluated.

Biosecurity policies at international life science journals

The prospect of bioterrorism has raised concerns about the potential abuse of scientific information for malign purposes and the pressure on scientific publishers to prevent the publication of "recipes" for weapons of mass destruction. Here we present the results of a survey of 28 major life science journals--20 English-language international journals and 3 Chinese and 5 Russian journals--with regard to their biosecurity policies and procedures. The survey addressed the extent to which life science journals have implemented biosecurity procedures in recent years, how authors and reviewers are advised about these procedures and the underlying concerns, and what the practical experiences have been. Few of the English-language publishers and none of the Russian and Chinese publishers surveyed implement formal biosecurity policies or inform their authors and reviewers about potentially sensitive issues in this area.